S 2610 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILOING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 2610
BUILDING PROJECT'IDENTIFICATION
RUILIIING AIIDREss: 9 SANITARY NO. APPLICATIIOONN SUBMITTAL HATE
VV\ r
OW . 'S NAME. aWI E, 1'RA 'OR'S NAM ax N
/0 :P— NIC CONTROL#
ARCH](GUVETNGINEF.R: I.IC NO. gyapyy; : •j ❑ /
CO 7 3 le, BUILDING PERMIT INFO
JOY D ❑ Consultant FfCS Paid by Applicant(Initial) EEOC I:LECI' PLUMB MECII
�J(f(aIN�LICFNSED CONTRACTOR'S DEC tAT a QTy, ELECTRIC PERMIT PEE
I hereby nation that I am licensed i nder,mansion.,of Chapter 9(commencing JOB DESCRIPTION
00p with Sectirn]II(Xpo(pivisionJnfshe Business and l'mf�es}yions C(t/�,1 a dmlylicense ix q RESIDENTIAL:
aUU 12cmc Fla in fall and cifecl. Lica 1 1 I J PERM]]'ISSUANCE J ❑SFDWI. CHpN REMODEL.
Dae f Cantmlam APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE.PIPE
RCHITEC"S DECLARATION PANPIS ❑MULT6IINIT ❑S'fRUCI'URAL
Z O In Z 1 understand my plans skull IN,used as public record..
024-C UP TO 2W AMPS MODIFICATION
Fr -h ul Lmenrad Pmlczsmnnl 201-IlXX1AM1'S O ❑ NINTERIOR
IMPROVEMENT ElCHIMNEY REPAIR
Sy Y 2l OWNER-RUILDER DECIARA'I'[ON C SWIMMING POOLS
—y C W 6 1 hereby aform that I am exempt tram the Contractor',License Law bathe OVER 0MAMPS ❑BATH REMODF.I/REPAIR ❑DEMOLITION
xx00.0 fillowingrcason.(Section]P51.5,Busine.usandl'mfessinns Code:Any city or county ❑OTHER
y7'31y F SIGNS Ii1.F.C1'RICAI.
F O ya which requires u permit m conssmn,alter,,.,.Brave,dmnnlish,o r part anY swan,.
w.4 priortoi¢Issmnce,aNom9uims'he
appliwmforseM1pemiinof gned.aamment SPECIALCIRCUl-UMISC. c e D
ssss >. thath,i.1w,mwdpursunot thc,rov:sionnofthc Conor is Li nee llawl Cl (commencingwith Se n]Il(Nllaf Divisinn3o he8 J :Code)or TEM1fI'.METER OR POLE(NST COMMERCIAL:
tY that he is exempt th efmm and the ba or the (leg punct.Any violation of
XmW Section 703 LS by ynppficunt feat b' th app u'antro acivil NEW BLDG/ADDITION [3 DEMOLITION
�..y n su Jc s penalty of POWER DEVICES 0'1*1?NANT ❑FOOD SERVICE
C Z y nn,come man nv Bored amp f&5a I.
_< El I......cro he prop, ,on em loyees hwagcsmthcu,.ic. Pension, SWIMMING POOL ELECTRIC IMPROVEMENT
F� wlll do the work, dthe ctarei noon ended nl,mtlbmd for mle(Sec.]M4,Il-are' /)os ❑OTHI?R
6'3 and I'nd'cavion, he contra tors I.iceme Law does nom aptly to an owner o OUTLI*1'S-SWI'(Cf11iS-FIXTURES V
Property who bullas r ,macs th am and who dies am,M1 work himself or thmug m
his own employees,p tried that such improvements arc nm intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the b idingor Improvement is sold wiminoneyeal-sml''cmoloction.lhe SQ.17.FLOOR ARITA SISQ.17.
ownervbuilder will have the burden of proving that he did not build or improve for pur-
es of,aln.f
us owner of the property,am exclusively contracting with licensed contractors to 1.'.
construct the project(Sec.7614,Business end Professions Code:)The Contmemr's Li.
cena,Law does not apply to an owner of property who builds or improves therm,suit QTY. I M .RM IT FEE
who contracts fnr such projects with a eomractorls)Incanted put must m the Contmemr!s
License law. s PERM - SSUnN
❑tum exqt under Sea B&1'Cf chi ass,.
r
Q , ALTER-p IN&VEN - AT[R IL'A) VALUATION
WORKGR:S OMPENSA N CLARp1zyltTq --� BACK FLOW PR CT, ICE 3 O 1D o Q
I hero y affirm under penalty of,agc,eco of the fn o ing liccluranons: 1
❑ (have and will for byneCion37M of the Labor
sure for Workers Comp en- DRAINS- R,R P ,GOND. STORIES TYP�CON UCNON
scion,as provided for by Sectio,.3]W of the LaMrr Gdc.for the performance of me Twp
work for which this penult is issued PIXTI]RES- � AI'
❑I have and will maintain Workers Compensation Insuran c m regnired by Section O
3]W of the laMCCsde.banks Performance of the work for which this permit is issued. GAS-EA.SYS
'IT3 -II TL
a OCC.TaBOUP
My Workers Cumpemsntlon Inaconce cortin and Policy nutnher arc; /Ll J. I/
Carrier: Policy No.: GAS-V .SYSTEM-O R )
CERTIFICATE 01:EXEMPTION FROM WORKERS' �
COMPFNSA'1'ION INSURANCE GREASFIJNDIISTRL WAS TF.I . CEPTOR
(This section need not bu completed if the is boron,hundred dollar(EIINp BUIIAING DIVISION FY.f?S
or InsJ GREASE TRA(' PLANCHECK PEE
Ioymyth:ninthe anymormeroa,nworktire subject
bjech tho the WikenuN,lsboE SEWER-SANITARY-STORM HA.2111117.
not enmLaw any person iany manner so u.m become subject to the Workers Compen' ENIiRGY FEE
Z
,anion laws or California.aDate
WATER HEATER W'Nf:NT/ELCCIR GRADING I'LE
Applicant
.~N. NOTICE TO APPLICAN'n If,alter making this Cemilicate of Exemption,you should WATER SYSTrAG7REATING
a hecomc subject wife Workers Compenxaion pmvisinns of the La or Code,you must SOILS EEC
{kl forthwith comply wimsucli provisions or this permit shall he deemed revoked. WATER SERVICE
aQ
;D z CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLMB. SQ.FE PAID
U Q (hereby affimr that there is a construction lending agency for the performance of D Receipt#
I, P the work fnr which Of,permit is issued(Sec.3197,Ci¢C.)
U Lenders Name
Lenders AddressTA TOTAL:
Ha 1 learnt,that 1 have read Ibis applicant,.end score that the nhoac fabrication is T D BUILDIN I'131i
IA correct.I agree,.comply with all city and county orunanees and state laws refusing,. QTY. MECHANICAL PERMIT FEE U admerngeconand tomato hereby outtionprposes representatives(if this city to enter upon the SBISMI BE O
above-nmeminncJ property for inspection purpose.,
P[RMII'ISSUANCE I)
agree to save.indemnify and keep harmless the City of Cupertino against ELIeCTRIE L-
lWe)ugIiabilimies,judgmer ,costs and expenses which may in anyway acerae C rE
against said City ql Tfill OR ADDTO MF:CH.
in ,.sequence of the grunting(11(his permit. Z0 PLUMBINGI 'E
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ID,IXp CFM)
S CE REGUL1ATI,ONS. MECHANICALFEE 70
Vjet
AIR HANDLING UNI'1'(OVER 111,01NI GI'M) CONSTRUCTION TAX
Sm of Ap,1wsm1Cnntn m I Ilut EXHAUST HOOD(WIDUC)
HAZARDOUS MAI'HRI IIS ( URE HOUSING MITIGA"PION FCIi
Will the applicant or morebuildingrccupant score or handle hazardmua material HEATING UNI'P TO I(0,1X10 RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc.Saco 5532(a)1 HEATING UNIT(OVER 100JXXIBTU)
[I No
VENTILATION FAN(SINGLE RRSID) PAID
Date ReceiptN
Will the applicant or future huddling occupant use cquil mmf or devices which
emit hazaou
dn air conmminants as defined by me Bay Area Air Quality Management BOILER-COMP OHPOR 100,0X)BTU)
District? ( L.
[:1 Yes BOILER-COMP(OVER I WAIT BOB
1 have mat the h:zadoux materialsAIR CONDITIONER ISSUANCE DATE
mgtimmems undo Chapter 6.95 of the Cali
home Health&Safety Cade,Sections 25511.5,25533 and 25534.1 understood that if the NEW RF IDENI'IAL MIiCH. SQ.FI'.
building does not currently have ,.,that it' ny respomeihilirym Drily the recupait s s_/
mcnts which ss rink mofa Cc ' of
O n u m nrizW agent ul TOTA
ISSUED BY.
OFFICE